Histopathologic Features of Adrenal Cortical Carcinoma
Alessandro Gambella, MD,* Marco Volante, MD, PhD,¡ and Mauro Papotti, MD, PhDt
Abstract: Adrenal cortical carcinoma (ACC) is a rare and aggressive malignancy that poses challenging issues regarding the diagnostic workup. Indeed, no presurgical technique or clinical parameters can reliably distinguish between adrenal cortical adenomas, which are more frequent and have a favorable outcome, and ACC, and the final diagnosis largely relies on histopathologic analysis of the sur- gical specimen. However, even the pathologic assessment of malignancy in an adrenal cortical lesion is not straightforward and requires a combined evaluation of multiple histopathologic features. Starting from the Weiss score, which was developed in 1984, several histopathologic scoring systems have been designed to tackle the difficulties of ACC diagnosis. Dealing with specific histopathologic variants (eg, Liss-Weiss-Bisceglia scoring system for oncocytic ACC) or patient characteristics (eg, Wieneke index in the pediatric setting), these scores remarkably improved the diagnostic workup of ACC and its subtypes. Nevertheless, cases with misleading features or discordant correlations between pathologic findings and clinical behavior still occur. Owing to multicentric collaborative studies integrating morphologic features with ancillary immunohis- tochemical markers and molecular analysis, ACC has eventually emerged as a multifaceted, heterogenous malignancy, and, while innovative and promising approaches are currently being tested, the future clinical management of patients with ACC will mainly rely on personalized medicine and target-therapy protocols. At the dawn of the new Fifth World Health Organization classification of endocrine tumors, this review will tackle ACC from the patholo- gist’s perspective, thus focusing on the main available diagnostic, prognostic, and predictive tissue-tethered features and biomarkers and providing relevant clinical and molecular correlates.
Key Words: adrenal cortical carcinoma, adrenal cortical tumor, diagnostic criteria, scoring systems, biomarkers (Adv Anat Pathol 2023;30:34-46)
A drenal cortical carcinoma (ACC) is a rare and aggres- sive malignancy of the adrenal cortex more frequently affecting females (1.5 to 2:1) with an estimated annual incidence of 0.7 to 2 patients/million and a bimodal inci- dence (2 peaks: in early childhood and adults in their fifth- seventh decade, respectively).1-4 As therapeutic options for ACC are limited and clinical outcomes are dismal, several aspects of this malignancy remain largely unexplored, kin- dling a more granular analysis to enhance its clinical man- agement. This review will tackle ACC from pathologist’s perspective, emphasizing the main diagnostic, prognostic,
and predictive tissue-tethered features along with clinically relevant scoring systems and correlates.
NOMENCLATURE AND DIAGNOSTIC CATEGORIES OF ADRENAL CORTICAL TUMORS AND DIFFERENCE FROM “HYPERPLASIA”
With the rise of imaging studies in clinical practice and the consequent increase of adrenal mass identification, the diagnostic spectrum of mass-forming adrenal conditions has widened, ranging from non-neoplastic conditions to aggressive malignant diseases (Fig. 1).5-12 Focusing on adrenal cortical tumors (ACTs), the primary diagnostic concern is the accurate and precocious assessment of the malignant potential of the lesion to guide subsequent ther- apeutic management and follow-up.13 Unfortunately, ACC can present clinical, laboratory, and imaging features over- lapping with other primary or secondary malignant lesions and with benign conditions.3,14-17 In addition, as innovative insights into molecular profiles and clonal analysis of adrenal cortical lesions are constantly revealed, new entities are now enlisted in the adrenal cortical proliferation group and will be integrated into the fifth World Health Organ- ization classification of adrenal cortical diseases. 13,18-22 Specifically, pathologists will be asked to discriminate between diffuse adrenal cortical hyperplasia, adrenal cort- ical nodular disease, adrenal cortical adenoma (ACA), and ACC.21
The distinction between ACA and ACC is challenging and has crucial consequences, as both the conditions could present similar features but opposite clinical outcomes. In the preoperative phase, several features, either from the clinic, laboratory, or imaging settings, were proposed to
Adrenal mass
-
Diagnostic options
Adrenocortical nodular disease
1) Adrenocortical hyperplasia
2) Adrenocortical adenoma
3) Myelolipoma
Malignancies
4) Pheochromocytoma”
1) Metastatic disease
5) Ganglioneuroma
2) Adrenocortical carcinoma
6) Hemangioma
7) Cyst&Pseudocyst
3) Primary adrenal lymphoma
4) Leiomyosarcoma
8) Angiolipoma
9) Adrenal bleeding/hematoma
5) Angiosarcoma
6) Liposarcoma
10) Tubercolosis
7) Neuroblastoma
From the Departments of *Medical Sciences; and +Division, University of Turin, Oncology, Pathology Turin, Italy.
The authors have no funding or conflicts of interest to disclose.
Reprints: Marco Volante, MD, PHD, Department of Oncology, Path- ology Unit, University of Turin, San Luigi Hospital, Regione Gonzole 10, Orbassano, Turin 10043, Italy (e-mail: marco. volante@unito.it).
All figures can be viewed online in color at www.anatomicpathology.com. Copyright @ 2022 Wolters Kluwer Health, Inc. All rights reserved.
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distinguish ACA from ACC, but none of them were conclusive.8,23-26 This evidence is particularly relevant as up to 10% to 15% of ACC are incidentally identified during imaging studies performed for unrelated reasons/causes (so-called “incidentalomas”).8,16,26-29 As no presurgical technique is diagnostically definitive, assessment of adrenal cortical lesion malignancy and ACC diagnosis largely rely on the pathologist analysis of the surgical specimen.
Pathology of Adult Adrenal Cortical Carcinoma
From a pathologic perspective, assessing the malignant nature of an adrenal tumor begins with the grossing pro- cedure. Indeed, ACC presents as a large, heterogenous mass usually measuring > 5 cm and weighing > 100 g, displaying a polylobular aspect and a yellow-to-ochre cut surface with foci of hemorrhage and necrosis.25,30,31 Macroscopic signs of invasion of the tumor capsule, periadrenal fat, large veins, and other adjacent organs should be carefully inves- tigated and reported, as they are key characteristics of ACC.25
The histopathologic features that suggest the malignant nature of adrenal tumors are both architectural and cyto- logic (Fig. 2). The growth patterns of ACC range from solid to trabecular, nested or alveolar, often presenting a variable proportion of architectural disarray and reticulin framework disruptions. Indeed, the reticulin stain represents a valuable support in confirming the diagnosis of ACC, and its assessment plays a fundamental role in the Reticulin Algo- rithm diagnostic tool.30,32-34 ACC cells are usually pleo- morphic, presenting a large cytoplasm with an eosinophilic (or rarely clear) appearance. Intranuclear inclusions and nuclear atypia are also frequently observed, leading to a grade 3 (irregular nuclei with prominent nucleoli at ×100
original magnification) or grade 4 (as grade 3 but with anaplastic cells) nuclear atypia score, according to Fuhrman criteria for renal cell carcinoma.35 Histopathologic signs of capsular and lymphovascular invasion (either venous or sinusoidal, defined as tumor cells breaching the vessel wall or located within the lumen but admixed with thrombus/ fibrin material) are particularly relevant and should be carefully evaluated and reasonably excluded. ACC is a proliferation-driven malignancy presenting an increased mitotic rate (>5 mitoses per 10 mm2/50 HPFs), bizarre/ atypical mitotic figures, and a Ki-67 index usually exceeding 5%.36-40 Notably, ACCs presenting >20 mitoses/50 HPF have a much poorer prognosis and are classified as high- grade ACC.41-43 Finally, intratumoral hemorrhage and necrosis are frequently observed, particularly in high- grade ACC.
In addition to the conventional form described thus far, different variants of ACC have been reported and include oncocytic, myxoid, and sarcomatoid that are defined based on their histopathologic features44-50 (Fig. 3). The oncocytic variant represents up to 18% of ACC cases and is charac- terized by large, granular, and eosinophilic (ie, oncocytic) neoplastic cells because of the increased concentration of intracellular mitochondria.37,49,51 Only cases with >90% oncocytic areas can be classified as pure oncocytic ACC and they demonstrated a better prognosis than conventional ACC.37,49,52,53 Lesions with lower percentages of oncocytic areas are defined as mixed (> 50%) or focal (<50%) onco- cytic ACC. Myxoid ACC represents almost 10% of ACC cases and is characterized by extracellular deposits of myx- oid Alcian blue positive material.45,46,48,53-55 Two sub- groups can be identified based on architectural and cytologic features.48 Group 1 is characterized by small/medium,
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bland-looking, and monomorphic neoplastic cells organized in a trabecular, pseudoglandular, or cribriform pattern. Group 2 includes cases with large, pleomorphic, and atyp- ical neoplastic cells with eosinophilic cytoplasm growing in a diffuse pattern, thus resembling a conventional ACC with myxoid degenerative areas.48 Regarding survival data, myxoid ACC presents a more aggressive behavior than conventional ACC, even in the pediatric setting.37,48,53,56,57 Finally, sarcomatoid ACC is extremely rare, highly aggressive, and can present with both areas of undiffer- entiated spindle cells or specific mesenchymal differentiation (eg, rhabdoid, chondroid, osteoid, and neuroectodermal), as the result of epithelial mesenchymal transition.50,58-67 For diagnostic purposes, the sarcomatoid area should represent at least 10% of lesion.50,53,67 Owing to the intrinsic aggres- sive nature of sarcomatoid ACC, malignant histopathologic features are very frequent and evident in (almost) all cases, thus leading to an easier morphologic distinction with ACA (but requiring a thorough evaluation to confirm the adrenal cortical nature depending on the sarcomatoid appearance extension). 50,55
Pathologic Criteria and Scoring Systems for Conventional Adrenal Cortical Carcinoma
Main pathologic features of ACC as compared with ACA are summarized in Figure 4.
The histopathologic distinction between benign and malignant adrenal cortical lesions could seem straightforward. However, apart from the macroscopic invasion of nearby structures, no single histopathologic trait indicates malignancy per se. Cases of misleading adrenal cortical masses (eg, rare
variants and subtypes, see below) or contrasting features (eg, small and localized lesions with malignant histopathologic features and large tumors with bland-looking neoplastic cells) may occur, leading to significant diagnostic pitfalls and ulti- mately making ACC a challenging diagnosis even for expert pathologists.12,25,28,32,37,42,51,53,55,68,69 To facilitate and stand- ardize ACC diagnosis, several multiparametric scoring sys- tems based on combined histopathologic features have been developed and tested and are now part of the routine diag- nostic workup.
The Weiss score was developed in 1984, but it remains one of the most commonly used scoring systems in clinical practice to classify conventional ACC in adults.40 It con- siders 9 histopathologic parameters (nuclear grade, mitotic rate, atypical mitosis, clear cells, diffuse architecture, necrosis, and vascular, sinusoidal, and capsular invasion), and the presence of 3 or more of these features indicates the malignant nature of the lesion. The Weiss score was modi- fied in 1989 and revised in 2002.70,71 In the revised version, the criteria were restricted to 5 (nuclear grade, diffuse architecture, and vascular and sinusoidal invasion were removed), but the mitotic count and clear cell parameters, if present, were counted twice. The malignancy cutoff remained the same (a score of ≥3 supported the ACC diagnosis). Although the diagnostic accuracy was imple- mented, such revised version did not replace the original Weiss system in the clinical practice.55
The Reticulin algorithm was proposed in 2009 using a slightly different approach, as it primarily considers the loss of the integrity of the reticulin framework as a key diag- nostic feature of ACC (Fig. 5).68 Of note, an intact reticulin
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ADRENAL CORTICAL MASS
- PATHOLOGICAL FEATURES
| Adrenal Cortical Adenoma ACA | Adrenal Cortical Carcinoma ACC | |
|---|---|---|
| Max diameter <2 cm Weight < 50 gr | Max diameter >5 cm Weight > 100 gr | |
| Well-defined cords, nests, and alveoli No signs of invasion Reticulin framework integrity | Solid, trabecular, nested, alveolar Capsular, vascular, sinusoidal invasion Architectural disarray & Reticulin framework disruption | |
| More regular appearance Minimal and focal nuclear atypia and cellular pleomorphism | Pleomorphic Large clear and granular or eosinophilic cytoplasm Intranuclear inclusion and nuclear atypia | |
| Few (< 5/10 mm ) and typical mitoses Ki-67 expression < 5% of neoplastic cells | 1 | >5 mitoses per 10 mm (50 high power fields)* Atypical mitoses Ki-67 expression >5% of neoplastic cells |
FIGURE 4. Schematic representation of the main histopathologic differences between ACA and ACC. * More than 20 mitoses/10 mm2 qualified the lesion as “high-grade ACC.” ACA indicates adrenal cortical adenoma; ACC, adrenal cortical carcinoma. Please see this image in color online.
framework is characterized by a mesh of homogeneous and regular fibers, completely surrounding nests or cords of adrenal cortical cells, as observed in the normal adrenal gland and ACA cases. Starting from this definition, the reticulin framework should be considered disrupted if any of these patterns are observed30,68.
(1) Quantitative alterations: characterized by various degrees of reticular fiber loss and disruption.
(2) Qualitative alterations: showing an apparently con- served but irregular mesh composed of heterogenous fibers with different thicknesses and surrounding small groups/single cells.
Apart from the specific type of alteration, if the retic- ulin framework is disrupted, a final diagnosis of ACC is made if any of the following histopathologic features are observed: > 5 mitoses/50 HPF, necrosis, and/or vascular invasion.30,68 The advantages of this approach are mainly related to its feasibility, reproducibility, and broad applic- ability regardless of the specific ACC histotype.30,33,42,68 Indeed, the reticulin algorithm proved to be a fast, easy- to-interpret, and reliable diagnostic tool, demonstrating a high interobserver reproducibility among the pathologists of different institutions (overall concordance rate of 86% after proper training). 30
A novel recently proposed scoring system is the Hel- sinki score.38 It was developed as follows: the presence of a high mitotic rate (defined as > 5 mitoses/50 HPF) scored 3 points and necrotic areas scored 5 points. Then, the numeric value of the proliferative index (calculated as the percentage of Ki-67-positive neoplastic cells in the most proliferative area) was added to obtain an overall final score that, if > 8.5, indicated a diagnosis of ACC. The additional value of
the Helsinki score is its prognostic potential, as a lesion that scored > 17 points harbored an increased risk of metastatic potential.31,38
A schematic comparison of the described scoring sys- tems is provided in Table 1.
Pathologic Criteria and Scoring Systems for Oncocytic and Myxoid Adrenal Cortical Carcinoma Variants
ACC histopathologic variants represent an additional caveat to the ACC diagnostic workup. Indeed, characterizing oncocytic lesion malignancy using the Weiss system is chal- lenging, as 3 criteria of this score (eosinophilic cytoplasm, high nuclear grade, and diffuse architecture) are intrinsically related to the oncocytic appearance, regardless of the malignant potential, thus increasing the risk of over- diagnosing malignancy.44 To solve this issue, the Lin-Weiss- Bisceglia system has been developed44,70,72 based on the evaluation of 3 major (mitotic rate >5/50 HPF, atypical mitoses, and venous invasion) and 4 minor (necrosis, capsular and sinusoidal invasion, size >10 cm, or weight >200 g) criteria. If any of the major criteria are present, the lesion is malignant, whereas, if only minor criteria are observed, the term oncocytic adrenal cortical neoplasm of borderline malignancy should be adopted. The Lin-Weiss-Bisceglia system is applied to pure oncocytic tumors only, thus requiring extensive lesion sampling to reasonably ascertain the correct percentage of the oncocytic component.49,52 Otherwise, the malignant nature of ACTs with mixed or focal oncocytic features should be evaluated with the conventional scoring systems.37,49,68
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Similarly, myxoid lesions generally lack a diffuse growth pattern and nuclear atypia, and the presence of abundant myxoid material could mask invasive features, leading to an increased risk of underestimating the malignant potential.37,48,54,55
ACC variants and their appropriate scoring systems are reported in Table 2.
Pathology of Pediatric Adrenal Cortical Tumors and Related Scoring Systems
Pediatric ACTs deserve a specific description, as they differ significantly from their adult counterparts.37,73 They usually occur before 5 years of age and show a remarkably increased frequency in the Brazilian population, as the
| TABLE 1. Scoring System for Adult ACC | |||||||
|---|---|---|---|---|---|---|---|
| Weiss System | Modified Weiss System | Reticulin Algorithm | Helsinki Score | ||||
| Parameter | Score | Parameter | Score | Parameter | Parameter | Score | |
| Nuclear grade* ≥3 | 1 | > 5 mitoses/ | 2 | Reticulin disruption | > 5 mitoses/ 50 HPF | 3 | |
| 50 HPF | |||||||
| > 5 mitoses/50 HPF | 1 | Atypical mitoses | 1 | > 5 mitoses/50 HPF | Necrosis | 5 | |
| Atypical mitoses | 1 | Clear cells ≤25% | 2 | Necrosis | Proliferative | Numeric value | |
| Index (Ki-67 IHC) | |||||||
| Clear cells ≤ 25% | 1 | Confluent necrosis | 1 | Vascular invasion | — | — | |
| Diffuse architecture | 1 | Capsular | 1 | — | |||
| >33% | invasion | ||||||
| Confluent necrosis | 1 | — | — | — | |||
| Vascular invasion | 1 | — | — | — | |||
| Sinusoidal invasion | 1 | — | — | — | |||
| Capsular invasion | 1 | — | — | — | |||
| ACC | Final score ≥3 | Final score ≥ 3 | Reticulin disruption | Final score >8.5 | |||
| diagnosis | (required) plus any of the | (if > 17, it indicates an adverse | |||||
| others | prognosis) | ||||||
*The nuclear grade is assessed according to the Fuhrman criteria as follows: grade 1: small and round nuclei, nonvisible nucleoli; grade 2: slightly larger and irregularly shaped nuclei, nucleoli visible with a high-magnification lens; grade 3: irregular and enlarged nuclei, nucleoli visible with a low magnification lens; grade 4: bizarre and extremely irregular nuclei, including monstrous cells.
ACC indicates adrenal cortical carcinoma; HPF, high-power fields (equivalent to almost 10 mm2).
| ACC Variant* | System Weiss | Algorithm Reticulin | Score Helsinki | Bisceglia System Lin-Weiss- |
|---|---|---|---|---|
| Conventional | v | v | v | — |
| Oncocytic | — | V | V | v |
| Myxoid | (v) *- | v | v | — |
*The rare sarcomatoid variant is not represented, as malignant histo- pathologic features are very common and evident because of its intrinsic aggressive nature.
+Weiss criteria may also be applied in myxoid variants. ACC indicates adrenal cortical carcinoma.
incidence is almost 15 times higher than that of the United States and Europe.56,74-76 In children, ACC is often part of genetic syndromes [eg, Li-Fraumeni syndrome (LFS)] and most cases are hormonally active, presenting with increased secretion of androgens (virilization; up to 80% of cases), glucocorticoids (Cushing syndrome; 14%), estrogens (femi- nization and gynecomastia; 7%), and aldosterone (hyper- tension, hypokalemia; 1% to 4%).26
The histopathologic distinction between benign and malignant lesions in the pediatric population is even more challenging than in the adult setting, considering that many more cases share misleading features and discordant clinic- pathologic correlations. This discrepancy is particularly evident when applying the Weiss system, thus leading, in 2003, to the development of a scoring system tailored for the pediatric population, the Wieneke index.74 It identifies 9 parameters (tumor weight >400 g, tumor size > 10.5 cm, vena cava invasion, periadrenal soft tissue and/or adjacent organ infiltration, necrosis, capsular invasion, vascular invasion, presence of atypical mitotic figures, and a mitotic count > 15/20 HPF) and stratifies ACTs in 3 groups: benign (up to 2 criteria observed), indeterminate for malignancy (3 criteria), and malignant (4 or more criteria). Compared with the Weiss and modified Weiss systems, the Wieneke index showed increased sensitivity and specificity in defining the malignant nature of pediatric adrenal cortical lesions and provided relevant prognostic data.56,74,76
Diagnostic, Prognostic, and Predictive Biomarkers of Adrenal Cortical Carcinoma
Ancillary immunohistochemical (IHC) markers sup- port the diagnostic, prognostic, and predictive workup of ACC37,41,42,51,53,55,77 (Fig. 6).
Steroidogenic factor 1 (SF-1), melan-A/MART-1, and a-inhibin are commonly used to confirm the primary adre- nal cortical origin and rule out medullary and extra-adrenal lesions.37,78 They are helpful also in defining ACC of ectopic adrenal tissue and in metastases.79 In particular, SF-1 emerged as the most reliable, with a diagnostic sensitivity and specificity of 98% and 100%, respectively.33,53,80-87 In addition, ACC can variably express mesothelial (calretinin and D2-40) and neuronal (synaptophysin and neurofila- ments) markers and is negative for epithelial membrane antigen, carcinoembryonic antigen, and chromogranin A.37,78 Cytokeratins are usually negative or focally positive in ACC, thus a strong and diffuse positivity in a malignant lesion in the adrenal calls into question the possibility of an adrenal metastasis. No significant differences were reported for the specific ACC variants, apart from a more frequent and intense neurofilament staining of the myxoid variant
and a lower intensity of SF-1 expression of oncocytic ACC.37,48,57,80 Regarding the sarcomatoid variant, adrenal cortical-specific markers expression is restricted to non- sarcomatous areas. 37,50,78
IHC also supports the distinction between benign and malignant proliferation in ambiguous cases. Several studies have confirmed the diagnostic reliability of Ki-67, ultimately leading to its inclusion in the Helsinki scoring system.31,38,88-95 Additional markers, such as phosphohi- stone H3 (to support mitotic index assessment), insulin-like growth factor 2 (IGF-2), p53, BUB1B, HURP, NEK2, and p27, have also been proposed for the diagnostic workup of ACC, but they actually present specific limitations (eg, p53 very low sensitivity and IGF-2 stain difficult interpretation), ultimately preventing their use in routine clinical practice.33,78,91,94,96 In addition, IHC could also answer a major clinical need represented by the diagnosis and treat- ment of hyperaldosteronism-related hypertension of adrenal origin and, in particular, unilateral aldosterone-producing adrenal cortical neoplasm.97-99 Recently, histomorphologic features and CYP11B-2 (cytochrome P450 family 11 sub- family B member 2, a steroidogenic enzyme producing aldosterone in the zona glomerulosa) IHC staining were recently combined into the HISTALDO classification to define a standardized histopathologic nomenclature system for aldosterone-producing adrenal cortical proliferation and provide a better predictive system for postsurgical hyper- aldosteronism recurrence.100-110 As a diagnostic category of the HISTALDO classification, aldosterone-producing ACC is defined by histopathologic scoring systems (including potential variants) and then characterized by CYP11B-2 expression.20,21,99,110-113 Notably, CYP11B-2 allowed to define specific genotype-phenotype correlations (such as CYP11B-2 expression and somatic mutations of ion channel proteins), but no pathology correlates have been identified so far.100-110
Considering the dismal survival rate of ACC, IHC expression of several markers was tested to assess whether it harbored prognostic potential and eventually supported ACC patient survival stratification.25,26,37 Ki-67 has emerged as the most reliable marker to predict survival in patient with ACC, ultimately outperforming the mitotic count. In particular, several studies have demonstrated that increased expression of Ki-67 is associated with reduced overall survival and increased ACC recurrence rate.96,114-119 The altered expression of p53, as a surrogate marker for the presence of TP53 mutation (occurring in 25% to 30% of sporadic ACCs and as a germline mutation in LFS), has been associated with advanced tumor stage and shorter disease-free survival.120-122 High levels of expression of SF-1 are also associated to a poor prognosis in ACC.80,83-85,123 Additional markers have also been evaluated, such as cyclin E, ß-catenin, matrix metalloproteinase type 2, and glucose transporter 1, but they currently lack proper validation in independent cohorts. 122,124-127
Predictive biomarkers are poorly represented in the ACC setting, mainly because of the currently limited ther- apeutic approaches that need predictor assessment. Indeed, apart from the surgical resection of early-stage lesions, mitotane is the most commonly used treatment in the adjuvant setting (alone) and advanced stages (combined in a chemotherapeutic set, such as the EDP-M scheme).128-135 Mitotane demonstrates a relevant antiadrenal effect, but the exact mechanism of action is still unclear: the identification of specific and reliable predictive markers is therefore
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challenging. To date, higher CYP2W1 (a P450 cytochrome member) and lower RRM1 (ribonucleotide reductase M1, an enzyme involved in deoxyribonucleotide synthesis) expression correlated with an improved response to mito- tane, but with a poor mechanistic explanation. 134,136-139 Innovative therapeutic approaches and associated predictive biomarkers are mainly related to immunotherapy and molecular-driven target therapy (eg, RAC1-VAV2 inhib- itors); however, although promising, they still need to be confirmed in validation cohorts. 81,140-142
Molecular Correlates of Adrenal Cortical Carcinoma
With the advent of molecular analysis, several mecha- nisms of ACT tumorigenesis were revealed, together with the additional identification of pathways and specific molecular signatures with clinical and diagnostic relevance.143
To date, the most relevant results of ACC molecular landscape characterization are represented by (1) the iden- tification of driver genes of adrenocortical tumorigenesis (eg, CTNNB1 and TP53), (2) the definition of specific
alterations supporting the discrimination between ACA and ACC (IGF-2 overexpression, homozygous deletions of ZNRF3 and KREMEN1, TERT amplification/promoter mutations, and chromosomal aneuploidy),25 (3) the description of prognostic subgroups (as identified by tar- geted gene expression, DNA-methylation signature, and next-generation sequencing) that proved to be particularly relevant in stage I to III ACC,25,144-147 and (4) the identi- fication of drug targetable alterations, even if in a relatively small percentage of cases (up to 16%).25,148,149
In particular, CTNNB1 activation and TP53 inactiva- tion (and related pathways) are considered key driver mutations in the ACT panorama. The role of CTNNB1- activating mutation in ACC was characterized in NCI- H295R ACC cell lines as a point mutation mostly involving Ser45 in exon 3.150 However, further detailing its prevalence in ACTs, it emerged that CTNNB1 is involved in both ACA and ACC tumorigenesis with similar prevalence.150 Because of that, CTNNBI mutation (and Wnt-ß-catenin pathway alterations) does not represent a specific signature to dis- tinguish ACC from ACA, regardless of its high recurrence
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in ACC.143,145,151 Similarly, TP53 somatic mutation is fre- quently observed in ACT series, and it represents, as part of the p53-Rb pathway, one of the most frequent mutations in ACC cases.145,152 In addition, TP53 germline mutation represents a crucial feature of genomic predisposition to ACC development, as will be discussed in the subsequent paragraph.
The molecular distinction between ACA and ACC is still challenging, as altered pathways and mutated genes often overlap. However, a recent DNA microarrays analysis identified a set of 2875 probes that are specifically under- expressed or overexpressed in ACC compared with ACA and normal adrenal tissue, including IGF-II.153 Indeed, studies on NCI-H295R ACC cell lines demonstrated that IGF-II induced a direct mitogenic effect via an IGF- IR-dependent mechanism, and its overexpression was then confirmed as a major specific characteristic of ACC in several studies. 94,120,153-156
Extensive ACC molecular studies allow identifying specific prognostic subgroups clustered by merging drive gene mutations, chromosomal aneuploidy, methylation status, and mRNA profile. The European Network for the Study of Adrenal Tumors identified 2 ACC categories, CIA and C1B, the former with poorer survival data.151,157 Sim- ilarly, by querying The Cancer Genome Atlas, 3 ACC cat- egories with prognostic relevance emerged: CoC I, II, and III145 (Table 3).
Unfortunately, despite the increasingly detailed ACC molecular characterization, the correlation between molec- ular data and specific histopathologic features is still poorly explored and is mainly related to ACC variants.53 Indeed, heterogenous expression of miRNAs among ACC variants has been reported, and PDGFR-ß gene amplification and a near-homozygous genome were observed in the oncocytic ACC variant, only.158-160
Genetic Predisposition in Adrenal Cortical Carcinoma
Most ACCs are sporadic cases, but up to 15% are related to germline mutations and developed as part of familial cancer syndromes. 37,144,145,152,161
In this setting, LFS is the most relevant because of its elevated prevalence in the pediatric population (50% to 80% of cases). 162,163 Overall, LFS is a rare autosomal dominant syndrome characterized by a high susceptibility to malig- nancies (lifetime risk of cancer: ≥ 70% for men and ≥90% for women), mostly represented by ACC, breast cancer,
central nervous system tumors, osteosarcomas, and soft tissue sarcomas. Cancer development predisposition in LFS is caused by the germline mutation of TP53 that mediates the activation of cell cycle arrest, DNA damage repair, and apoptosis pathways.164,165 Of note, as TP53 germline mutations is frequently observed in ACC pediatric patients, it is less commonly observed in adult patients (5% to 10% of ACC).152,166-168 In particular, the R337H mutation (ie, the Arg to His substitution at codon 337) is particularly fre- quent in the pediatric population of Southern Brazil, where ACC prevalence is remarkably increased.163,169-173
An additional syndrome with a peculiar pediatric relevance is the Beckwith-Wiedemann syndrome (BWS). BWS is a rare and complex syndrome that could be caused by various epigenetic and/or genetic alterations involving imprinted genes at chromosome 11p15.5.174-180 In the con- text of signs and symptoms of overgrowth and congenital malformations, ~5% to 10% of patients (lifetime risk: 7.5%) presented an increased risk of developing (embryonal) malignancies (eg, Wilms tumor, hepatoblastoma, neuro- blastoma, and rhabdomyosarcoma), most commonly occurring within the first 8 years of life.181-184 ACC occurs in 7% of the BWS patients developing malignancies because of IGF-II overexpression and H19 and p57kip2 inactivation. 175,185
ACC may also be genetically determined in the Lynch syndrome (LS) context. LS is an autosomal dominant syn- drome characterized by the inactivating germline mutations of one of the mismatch repair genes (MSH2, MSH6, MLH1, and PSM2). Clinically, LS patients have an increased risk of several malignancies, including colorectal cancer (lifetime risk: 35% to 80%) and endometrial cancer (lifetime risk: 34% to 71%).166,186,187 Regarding ACC, the prevalence of LS is 3.2% (similar to colorectal and endo- metrial cancer and overall increased compared with the general population). 186
Other inherited cancer syndromes in which adreno- cortical neoplasia occurs are multiple endocrine neoplasia type 1 (MEN1-inactivating mutation), familial adenoma- tous polyposis (APC-inactivating mutation), neuro- fibromatosis type 1 (NF1 mutation), and Carney complex (PRKAR1A-inactivating mutation). However, in these syn- dromes, ACTs are mainly represented by adrenal cortical hyperplasia and ACA, whereas ACC rarely occurs. 152,162,188 Nevertheless, genetic counseling and screening for germline mutations should be recommended for all patients with ACC, especially in the pediatric setting.21,146 Most relevant
| TABLE 3. ACC Molecular Stratification With Prognostic Relevance | ||
|---|---|---|
| Subgroup | Molecular Signature | Clinical Implication |
| ENS@T | Drive gene mutations (CTNNB1; TP53; ZNRF3) Intermediate/high CIMP methylation | |
| C1A | Reduced OS | |
| C1B | Low CIMP methylation | Improved OS |
| TCGA | ||
| CoC I | Drive gene mutations (ZNRF3); MSI Low CIMP methylation | Improved EFS |
| CoC II | Drive gene mutations (CDKN2A, CTNNB1, NF1, TP53, ZNFR3, PRKAR1A) Intermediate CIMP methylation | Intermediate EFS |
| CoC III | Drive gene mutations (CDK4, CDKN2A, CTNNB1, MLL4, RB1, TERT, TP53, ZNFR3) High CIMP methylation | Reduced EFS |
ACC indicates adrenal cortical carcinoma; EFS, event-free survival; MSI, mutations of mismatch repair-related genes; OS, overall survival; TCGA, The Cancer Genome Atlas.
| TABLE 4. Germline Mutations and Related Syndromes Associated With ACC | |||
|---|---|---|---|
| Syndrome | Molecular Signature | ACC Frequency | Associated Tumors |
| Li-Fraumeni | TP53-inactivating mutation | 4%-6% (50% in the pediatric population) | Breast cancer; soft tissue sarcomas (osteosarcomas); central nervous system tumors |
| Beckwit-Wiedemann | 11p15.5 imprinted genes mutations or deletions | ~7%* | Malignancies of embryonal origin/phenotype (Wilms tumor, hepatoblastoma, neuroblastoma, rhabdomyosarcoma) |
| Lynch | MLH1, MSH2, MSH6, and PMS2 mutations | ~3% | Several [gastrointestinal carcinoma (CRC; stomach, small bowel) gynecologic carcinoma (endometrial and ovary carcinoma)] |
| Multiple endocrine neoplasia type 1 | MEN1-inactivating mutation | NA | Neuroendocrine tumors (parathyroids, gastroenteropancreatic tract, and anterior pituitary gland) |
| Familial adenomatous polyposis | APC-inactivating mutation | NA | Colorectal adenomas |
| Neurofibromatosis type 1 | NF1 | NA | Neurofibromas; MPNST |
| Carney complex | PRKAR1A-inactivating mutation or deletion | NA | Myxomas (heart, breast); thyroid cancer (both PTC and FTC); neuroendocrine tumors |
*The percentage refers to the 5% to 10% of patients developing tumors in the context of the Beckwith-Wiedemann. ACC indicates adrenal cortical carcinoma; CRC, colorectal carcinoma; FTC, follicular thyroid cancer; MPNST, malignant peripheral nerve sheath tumor; NA, not available; PTC, papillary thyroid cancer.
germline mutations and related syndromes are reported in Table 4.
Future Perspective
Relevant advances related to the ACC diagnostic and prognostic evaluation have been achieved owing to multi- disciplinary expert team-driven studies. However, several areas need to be thoroughly defined and kindled detailed analyses, starting with the identification of new biological markers, therapeutic approaches, and predictive algorithms. Tailored diagnostic approaches based on histopathologic features and patient characteristics were shown to remark- ably improve the clinical management of ACC patients, thus revealing how a personalized approach to ACC will repre- sent the future of this rare malignancy.
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